Making the grade
Use only high-quality evidence in EBP
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By Karen Schmidt, RN
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EDITOR'S NOTE: Karen Schmidt, RN, is a freelance writer.
Evidence-based practice has advanced and led to improvements in nursing care. But nurses who depend on an EBP model cannot stop using their critical thinking and nursing assessment skills when applying that model to their patient care.
“Evidence is a moving target,” said Patricia A. Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP. A nurse consultant, Quigley is the retired associate director of Veterans Integrate Service Network 8 Patient Safety Research Center of Inquiry. She worked in rehabilitation nursing since 1977, serving with the Veterans Administration for 32 years.
“I created a research agenda to address gaps in practice and led research programs to fill the gap,” she said. Her research also revealed that, in EBP, not all the scientific evidence is equal. "A lot of nurses think they’re doing EBP; they need to read the literature content and grade the evidence,” she said.
Quality of nursing care depends on the quality of the evidence, she said. “When you’re conducting research, you have to ask, ‘What is the state of the science?’” she said. "There needs to be sufficient science out there before practice is changed as a result.” Quigley recommended using grading scales to evaluate the evidence. Various scales exist, for example, United States Preventive Services Task Force Grading.

Examples of Evidence-Based Practice To reach and maintain best quality of care and true EBP, nurses should be primarily using grade A evidence. It is plentiful, tried and true, she said. For example, she said, nurses must evaluate the competency of the evidence for the use of nonskid socks. “If you look at the literature, the universal precautions say to put patients in the socks. If you’re putting them on everyone, you’re not using the evidence; you’re putting them on some of the wrong people.” Patients with a shuffling gait should not wear nonskid socks for falls prevention because the socks increase their trip hazard. Nurses who evaluate the practice based on the most competent, higher grade evidence will make the necessary critical decisions based on their assessments.
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There needs to be sufficient science out there before practice is changed as a result.”
— Patricia A. Quigley, ARNP
Qualifying research
Amy Hester, PhD, RN, BC, agreed that implementing EBP means going beyond a simple screening tool. “EBP guides decision-making so nurses can choose what interventions and EBP are best for each patient. It allows the nurse to personalize and individualize care for preventing falls with injury,” she said.

Hester is director of nursing research and innovation for University of Arkansas for Medical Sciences in Little Rock. Her research led her to co-develop the Hester Davis Scale for Fall Risk Assessment. While working on a neurology/neurosurgery unit in 2008, Hester began researching falls prevention after recognizing that the unit had a problem.

“Nurses used an EBP bundle in preventing falls, but didn’t evaluate which single practices [in the bundle] were needed," she said. In 2010, after a fall-related patient death, her research team started testing single interventions to find out what was effective in preventing falls and what wasn’t. "When we implemented the EBP model, we found that the risk assessment tool didn’t point us in the right direction about what patient needed what care.”
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Steps in implementing EBP
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Choose an EBP model and build the infrastructure to use it, Quigley recommended. If you know you have a gap in evidence, how will you close the gap? The model should guide nurses in how to review the science and go from inquiry to implementation. Choose a grading scale to evaluate the competency of the evidence and teach people how to use it.
Ask, "Do we have a staffing issue that doesn’t make this process feasible?" If so, don’t use that model, Hester said.
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Start small. Make small tests of change first. If it doesn’t work, figure out why. “Be ready for barriers to implementation,” Quigley said.
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Evaluation should be part of the model. “You need to be thoughtful of how you incorporate evidence into practice, or you set yourself up for failure,” Hester said.
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“Evidence-based practice is closing the gap between what’s out there and what we’re doing,” Quigley said. “People are more engaged. They feel they have more autonomy. People love to see how they’re making a difference.”
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Hester also said staffing, among other components, is affected by EBP. “It directly impacts the time nurses have to spend in implementing EBP,” she said. “Time equates to compliance," she continued. "How compliant is the nurse in keeping to the standards of the institution? The connection is that you can have all the EBP related to any outcome or treatment plan, but if staffing issues mean a nurse doesn’t have enough time, there cannot be compliance with that EBP.” In applying science to practice, Hester, like Quigley, said evidence needs regular evaluation. “EBP is in constant evolution,” she said. “It’s never a stagnant set of rules — there is always new evidence and new science. We have to keep a pulse on things that are coming out.”
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Quigley’s research has shown her that not all scientific evidence is of equal importance. For example, as a clinical nurse specialist, she read literature about the effectiveness of fall and fall injury prevention programs in hospitals, and found little evidence of effectiveness. However, literature was available in long-term care and primary care settings. She questioned how to apply this knowledge to acute care settings through quality improvement and program evaluation.
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Get to the root of it
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Master the basics of EBP and learn how to start your own project.
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Research seeds practice
Turn a patient care idea into evidence-based practice by starting with solid research.
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Fuel career satisfaction
Rejuvenate your career with new evidence that transforms old practices.
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EBP blasts make an impact
A nurse who manages six clinics successfully expands healthcare access and relieve congestion.
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CE Catalog
Boost your knowledge of evidence-based practice processes in various settings with these education offerings.
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Self-care is a safety issue
Nurses who work nights or rotating shifts can suffer from sleep deprivation, which negatively impact their health and puts patients at risk.
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Create a dream team
Interprofessional collaboration and care has the potential improve outcomes and processes.
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Follow the evidence
You know EBP is important; now grasp the strategies and thought processes behind it by taking this CE module.
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Pregame practice for students
Nursing students are being taught the importance of providing high-quality care that’s supported by evidence.
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TeamSTEPPS improves communication
TeamSTEPPS was created as a nursing strategy to improve patient safety. Learn how the model took shape.
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Elevate your care
Learn why evidence-based practice is a must when it comes to quality patient care.
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Hold the power for change
Bedside nurses have the ability to make significant practice changes in the workplace.
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Making the grade
Use your critical thinking skills to continue to reevaluate evidence and adjust EBP, if necessary.
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Protect them from pain
Age-appropriate EBP helped nurses reduce pain levels in their young patients.
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The journey continues
Nurse leaders have the difficult task of increasing participationin EBP, but they know it’s worth the effort.
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An unacceptable risk
Perioperative nurses are striving to decrease the risk of hospital-acquired pressure ulcers.
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Training days
Managing the healthcare of specific patient populations using EBP to drive clinical decision making has become a necessity.
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Patient care gets revamped
Cancer center uses evidence-based studies and patient input to make changes to bedside reporting, elevate patient safety and improve care.
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